Every finding on record at Orange County Care Hospice Inc.

Observed in Record Review. In 1 of 10 active patient records reviewed, the organization did not document a patient specific comprehensive assessment that identified the need for physical, psychosocial, emotional, and spiritual care. In the record of RRNHV#7 there was no psychosocial assessment documented for a patient admitted 14 days prior to this survey date. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization did not include all criteria outlined in policy to screen, assess, and reassess pain for those patients who were verbal and able to answer questions. For example, in records RRHV#1, RRHV#3, RRNHV#2, RRNHV#3, and RRNHV#6 assessments did not include pain history, effectiveness of interventions, pain goals, and other elements specified in the pain assessment policy. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 8 of 8 patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. For example, in records RRHV#1, RRHV#2, RRHV#3, RRNHV#1, RRNHV#2, RRNHV#3, RRNHV#4, and RRNHV#5 the interdisciplinary group did not document patient decline, progress towards desired outcomes and goals, and plans for the next two weeks in meeting notes. Rather, the most recent skilled nurse note was copied, and there were no notes written by psychosocial and spiritual services. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services. Observed in Record Review. In 3 of 10 active patient records reviewed, the interdisciplinary group did not update the comprehensive assessment every 15 days or less. For example, in record RRNHV#1 a registered nurse updated the comprehensive on day 17 and again on day 19. In record RRNHV#2 the nurse documented an update on day 18 and again on day 25. In record RRNHV#3 an update was documented on day 22. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 1 of 10 active patient records reviewed, the organization did not notify the physician when there was an unanticipated change in the patient’s condition. In record RRHV#1 a registered nurse documented that the patient refused to have a foley catheter changed as ordered. The catheter was flushed with 120 milliliters of sterile water. The nurse documented that the patient tolerated the procedure “poorly”, complained of pain at the foley insertion site, was febrile at 100.6 degrees Fahrenheit, and that the urine returned after flushing the catheter was pink tinged. There was no documentation in the record that the medical director was notified. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Patient Home. In 3 of 3 home visits conducted, the organization did not ensure use of standard precautions during patient care. At RRHV#1 an HHA correctly performed hand hygiene with soap and water prior to providing care. However, between doffing and donning gloves she failed to perform hand hygiene using hand sanitizer gel. At RRHV#2 and RRHV#3 a spiritual counselor and a registered nurse failed to perform hand hygiene prior to initiating care. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Competency Session. the organization did not ensure that staff were oriented to their job duties. In personnel file HR#10 MD the physician did not receive a description of his job duties specific to the role of medical director as part of orientation. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Competency Session. In 3 of 10 HR files reviewed, the organization did not ensure that competence was assessed at hire in compliance with HR policy and law. In personnel files HR#7 VO, HR#9 AMD and HR#10 MD competency was not assessed at 90 days as required by policy. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.

Observed in Record Review. In 10 of 10 active patient records reviewed, the organization’s plan for providing patient care and support did not include an emergency preparedness plan individualized to patient’s needs that was reviewed and confirmed with patients, families, and caregivers. Emergency plans were not found in patient folders at home visits, nor was there documentation in patient records that education was provided. This RFI was reviewed and discussed with the Administrator/Director of Patient Care Services.